Reporting Harm

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Reporting Harm

Please describe the incident in as much detail as you're comfortable with sharing. *

Date of Incident *

YYYY

Location of Incident

Working group meeting

Project group meeting

One-on-one with project leader

Email or written documentation

Other:

Clear selection

Name of people involved in the incident

Do you have any suggestions on the way you wish the committee to respond to the situation?

Formal apology

Mediated conversation

Separate respondent from shared working space

Remove respondent from project or working group

No action

Other:

Would you like to remain anonymous? *

Yes

If you would like to remain anonymous throughout the process (answered YES to above question), please do not fill in SECTION 2. Note that we will still address the harm reported, but you will not receive any information or updates regarding the case.

If you would like to be contacted by the grievance/harm response team, but still remain anonymous to the larger collaboration (answered NO to the above question), please fill in the details requested in SECTION 2. Note that no one in SEISMIC will receive any information regarding the case, except the people identified in the incident.

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